VA Class: DE102
Chemical Name: cis-1-acetyl-4-[4-[[2-(2,4-dichlorophenyl)-2-(1H-imidazol-1-ylmethyl)-1,3-dioxolan-4-yl] methoxy]phenyl] piperazine
Molecular Formula: C26H28Cl2N4O4
CAS Number: 65277-42-1
Brands: Extina, Nizoral, Nizoral A-D, Xolegel
Antifungal; azole (imidazole derivative).1 3 4 5 6 11 23 32 72 105 106 110
Uses for Ketoconazole
Treatment of tinea corporis, tinea cruris, and tinea pedis caused by Epidermophyton floccosum, Trichophyton mentagrophytes, or T. rubrum.1 2 25 27 28 56 58 59 60 61 62 66 78 79 110
A drug of first choice for topical treatment of tinea corporis or tinea cruris.81 85 Oral antifungals preferred when tinea corporis or tinea cruris is extensive, dermatophyte folliculitis is present, infection is chronic or does not respond to topical therapy, or patient is immunocompromised or has coexisting disease.80 81 82 83 84
Treatment of cutaneous candidiasis caused by Candida albicans.1 2 25 58 59 67 68 69 110
Pityriasis (Tinea) Versicolor
Treatment of pityriasis (tinea) versicolor caused by or presumed to be caused by Malassezia furfur (Pityrosporum orbiculare or P. ovale).1 2 25 26 63 72 97 110
Seborrheic Dermatitis and Dandruff
Treatment of seborrheic dermatitis, including seborrheic dermatitis of the scalp.1 12 42 43 44 67 71 73 76 98 99 101 103 105 106 107 108 109
Self-medication (OTC use) for reduction of flaking, scaling, and itching associated with dandruff.74 75 77 99 100 101 102 104
Ketoconazole Dosage and Administration
Apply topically to skin as a 2% cream,1 110 foam,106 gel,105 or shampoo.72 97
Cream, foam, gel, and shampoo are for external use only.1 72 104 105 106 Do not apply to eyes1 72 104 105 106 and do not administer orally105 106 or intravaginally.56 57 105 106
If contact with eyes, mouth, or vagina occurs, rinse thoroughly with water.104 106
When using the 2% foam, hold the can containing the foam upright and spray a small amount into the cap of the can or other cool surface.106 Do not dispense foam directly onto affected areas or onto hands since the foam will begin to melt immediately on contact with warm skin.106 If fingers are warm, rinse them in cold water and dry before handling the foam.106 Using the fingertips, gently massage small amounts of foam onto affected areas until the foam disappears and entire affected area has been treated.106
When using the 2% gel, do not apply sunscreen or cosmetics to the affected area until at least 20 minutes after application of the gel.105 Do not wash the affected area for at least 3 hours after application of the gel.105
Avoid fire, flame, and/or smoking during and immediately after application of 2% foam or gel.105 106 (See Flammability under Cautions.)
Topical Seborrheic Dermatitis in Children ≥12 Years of Age
2% gel: Apply to affected areas once daily for 2 weeks.105 107 108
2% foam: Apply to affected areas twice daily for 4 weeks.106 109
Dandruff in Children ≥12 Years of Age
1% shampoo: For self-medication, apply to wet hair, lather, and rinse thoroughly; then repeat application, lathering, and rinsing.104 Use every 3 or 4 days for up to 8 weeks as needed or as directed by a clinician.104 Thereafter, use as needed to control dandruff.104
Tinea Corporis or Tinea CrurisTopical
2% cream: Apply and rub gently into affected and surrounding area of skin once or twice daily for 2 weeks.1 2 25 58 59 62 110 There is some evidence that twice-daily regimen may occasionally be more effective than once-daily regimen.25 62 If clinical improvement does not occur after treatment, reevaluate diagnosis.1 110
2% cream: Apply and rub gently into affected and surrounding area of skin once or twice daily for 6 weeks.1 2 60 66 79 110 If clinical improvement does not occur after treatment, reevaluate diagnosis.1 110
Moccasin-type (dry-type) tinea pedis may require more prolonged therapy.66 79
2% cream: Apply and rub gently into affected and surrounding area of skin once or twice daily for 2 weeks.1 2 25 58 59 110 If clinical improvement does not occur after treatment, reevaluate diagnosis.1 110
Pityriasis (Tinea) Versicolor
2% cream: Apply and rub gently into affected and surrounding area of skin once daily for 2 weeks.1 110 If clinical improvement does not occur after treatment, reevaluate diagnosis.1 110
2% shampoo: Apply to damp skin of the affected area and a wide margin surrounding this area and lather; after 5 minutes, rinse with water.72 A single application should be sufficient,72 97 although once-daily application for 3 days also has been used.97
2% cream: Apply and rub gently into affected areas twice daily1 12 42 43 44 67 71 for 4 weeks or until clinical clearing.1 12 42 43 44 71
2% foam: Apply and gently massage into affected areas twice daily for 4 weeks.106 109
2% gel: Apply to affected areas once daily for 2 weeks.105 107 108
2% shampoo: For seborrheic dermatitis of the scalp†, has been used to wash the hair and scalp 2 or 3 times weekly for 2–4 weeks.76 98 99 101 After a response was obtained, has been used once weekly every other week to prevent relapse.98
1% shampoo: For self-medication to control flaking, scaling, and itching associated with dandruff, apply to thoroughly wet hair, lather and rinse thoroughly; then repeat application, lathering, and rinsing.104 Use every 3 or 4 days for up to 8 weeks as needed or as directed by a clinician.104 Thereafter, use as needed to control dandruff.104
2% shampoo: For treatment of dandruff†, has been used to wash the hair and scalp 2 or 3 times weekly for 2–4 weeks.76 98 99 101 After a response was obtained, has been used once weekly every other week to prevent relapse.98
Cautions for Ketoconazole
Hypersensitivity to ketoconazole or any ingredient in the formulation.1 72 105 110
Contact dermatitis reported following topical application of ketoconazole or other imidazole-derivative azole antifungals.61 89 90 91 92 93 94 110
If a reaction suggesting sensitivity or chemical irritation occurs (e.g., rash), discontinue the drug.1 72 104 105 106 110
Possible cross-sensitization among the imidazole derivatives.89 90 91 92 93 94
Some formulations of the 2% cream contain sodium sulfite, which may cause allergic-type reactions (including anaphylaxis and life-threatening or less severe asthmatic episodes) in certain susceptible individuals.110 Overall prevalence of sulfite sensitivity in the general population is unknown, but probably low; such sensitivity appears to occur more frequently in asthmatic than in nonasthmatic individuals.110
Systemic Adverse Effects
Although hepatotoxicity, decreased testosterone concentrations, and decreased ACTH-induced corticosteroid concentrations have been reported with oral ketoconazole,32 105 110 these adverse effects have not been reported with topical ketoconazole105 110 and are unlikely since the drug does not appear to be appreciably absorbed following topical application to skin.2 56 57
2% foam and gel are flammable.105 106 Avoid fire, flame, and/or smoking during and immediately after application of foam or gel.105 106 (See Storage under Stability.)
Category C.1 72 105 106 110
2% cream, foam, gel, or shampoo: Use during pregnancy only when potential benefits justify possible risks to the fetus.1 72 105 106 110
1% shampoo: Pregnant women considering self-medication should consult a clinician before using the preparation.104
Not known whether ketoconazole distributed into milk following topical application.1 105 106 110
2% cream: Discontinue nursing or the cream.1 110
2% foam, gel, or shampoo: Use with caution.72 105 106
1% shampoo: Nursing women considering self-medication should consult clinician before using the preparation.104
2% cream: Safety and efficacy not established in children;1 110 has been used without unusual adverse effect in children 2 days to 12 years of age.15 17
2% foam: Safety and efficacy not established in children <12 years of age.106
2% gel: Safety and efficacy not established in children <12 years of age.105
1% shampoo: Safety and efficacy for self-medication not established in children <12 years of age.104
2% shampoo: Safety and efficacy not established in children.72
Common Adverse Effects
2% cream: Local reactions at application site (severe irritation, pruritus, stinging).1 2 25 26 58 59 60 61 110
2% foam: Application site reactions (e.g., burning).106 109
2% gel: Application site reactions (e.g., burning), headache.105 107 108
2% shampoo: When applied to the skin, pruritus, application site reaction, dry skin.72 When applied to scalp, increased hair loss, irritation, abnormal hair texture, loss of hair curl in patients with permanently waved (“permed”) hair, scalp pustules, dry skin, pruritus, oiliness or dryness of the hair and scalp.72
Interactions for Ketoconazole
No formal drug interaction studies to date.105
Ketoconazole does not appear to be appreciably absorbed systemically following topical application to skin or scalp.1 2 24 25 56 63 72 105 106 110
2% cream: Topical application to chest, back, and arms of healthy adults with intact skin does not result in detectable blood concentrations.1 2 24 110 Following topical application in vitro in a skin model, ketoconazole was retained in the stratum corneum and the boundary of the stratum corneum and stratum granulosum for up to 16 hours.56 63
2% foam: Topical application of 3 g twice daily for 4 weeks in patients with moderate to severe seborrheic dermatitis resulted in plasma ketoconazole concentrations <6 ng/mL in 75% of patients; maximum plasma concentration was 11 ng/mL.106
2% gel: Topical application once daily for 2 weeks (0.05-3.47 g daily) in patients with severe seborrheic dermatitis (1–14% of body surface area) resulted in mean peak plasma concentrations of 1.35 ng/mL on day 7 and 0.8 ng/mL on day 14.105
2% shampoo: Chronic use of 2% shampoo (4–10 times weekly for 6 months, 2–3 times weekly for 3–26 months) did not result in detectable plasma concentrations.72
Small amounts of ketoconazole are absorbed systemically when the drug is administered intravaginally.24
Not known whether ketoconazole distributed into milk following topical application of 2% cream, foam, gel, or shampoo.1 105 106 110
20–25°C110 or 15–30°C,1 depending on manufacturer.
20–25°C; do not refrigerate or freeze.106
Flammable; do not store in direct sunlight and do not expose to heat or temperatures >49°C.106 Do not puncture and/or incinerate container.106
25°C (may be exposed to 15–30°C).105
2–30°C; protect from light and freezing.104
≤25°C; protect from light.72
Actions and Spectrum
Imidazole-derivative azole antifungal.1 3 4 5 6 11 23 32 72 105 106 110
Structurally related to other imidazole-derivative azole antifungals (e.g., butoconazole, clotrimazole, econazole, miconazole, oxiconazole, sulconazole, tioconazole).3 4 5 6 11 23
Usually fungistatic; may be fungicidal at high concentrations after prolonged incubation or against very susceptible organisms.3 5 21 34 48 49 50 52 53 54 55
Presumably exerts its antifungal activity by altering cellular membranes, resulting in increased membrane permeability, secondary metabolic effects, and growth inhibition.1 21 23 32 48 49 50 51 52 55 105 106 110 Fungistatic activity may result from interference with ergosterol synthesis.1 21 34 49 50 51 55 105 106 110 Fungicidal activity at high concentrations may result from a direct physiochemical effect on the fungal cell membrane.3 55
Mechanism(s) of action in the treatment of dandruff not fully determined.72
Spectrum of antifungal activity includes many fungi, including yeasts and dermatophytes.1 2 3 10 22 32 40 72 110
Dermatophytes: Active against Epidermophyton floccosum,1 4 6 10 22 32 40 72 110 Microsporum audouini,1 10 22 32 40 72 110 M. canis,1 4 10 22 32 40 72 110 M. gypseum,1 4 10 22 32 40 72 110 Trichophyton mentagrophytes,1 4 10 22 32 40 72 110 T. rubrum,1 4 10 22 32 40 72 110 and T. tonsurans.1 4 10 22 32 40 72 110
Other fungi: Active against Candida albicans,4 5 6 7 8 10 22 32 36 40 72 110 C. tropicalis,72 110 and Malassezia furfur (Pityrosporum orbiculare, P. ovale).1 39 40 45 72 105 106 110
Advice to Patients
Importance of using the medication for the full, prescribed treatment period, even if symptoms improve; importance of consulting with clinician if the skin condition does not improve after a full course of therapy.56 57 104 106
Importance of discontinuing use1 72 104 105 110 and contacting clinician if signs or symptoms of irritation or sensitization occur.56 57 104 105 106
Importance of not applying 2% cream, foam, or gel to eyes1 105 106 or intravaginally.56 57 105 106
If using 2% foam or gel, importance of avoiding fire, flame, and/or smoking during and immediately following application.105 106 Importance of not throwing foam container into a fire, even if can is empty.106
If using shampoo, importance of avoiding contact with eyes;72 104 if contact with eyes occurs, rinse thoroughly with water.104
Importance of not using the 1% shampoo for self-medication of dandruff if the scalp is broken or inflamed.104 Importance of discontinuing use and contacting a clinician if rash occurs or the condition worsens or does not improve within 2–4 weeks.104
Importance of informing clinicians of existing or contemplated therapy, including prescription and OTC drugs, or any concomitant illnesses.1 105
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1 72 104 105 106 110
Importance of informing patients of other important precautionary information. (See Cautions.)
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
AHFS DI Essentials. © Copyright 2018, Selected Revisions July 1, 2009. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.
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